A 6-year audit of public-sector MR utilisation in the Western Cape province of South Africa

Background Disparities in MR access between different countries and healthcare systems are well documented. Determinants of unequal access within the same healthcare system and geographical region are poorly understood. Objective An analysis of public sector MR utilisation in South Africa’s Western Cape province (WCP). Methods A retrospective study of WCP MR and population data for 2013 and 2018. MR units/106 people, studies, and studies/103 people were calculated for each year, for the whole province and the ‘western’ and ‘eastern’ referral pathways, stratified by age (0–14 years, > 14 years) Results Between 2013 and 2018, the WCP population increased 8% (4.63 vs 5.08 × 106 people) while MR resources were unchanged (‘western’ = 2 units; ‘eastern’ = 1), equating to decreasing access (units/106 people) for the province (0.65 vs 0.59; –9.2%), the ‘western’ (0.97 vs 0.9; –7.2%) and ‘eastern’ (0.39 vs 0.35; -10.3%) pathways. In 2013, 40% (4005/10 090) of studies were in the ‘eastern’ pathway serving 55% (2 066 079/4 629 051) of the population. Between 2013 and 2018 ‘eastern’ population growth (n = 286 781) exceeded ‘western’ (n = 168 469) by 70% (n = 118 312). By 2018, 38% (7939/12 848) of studies were performed in the ‘eastern’ pathway, then serving 56% (2 849 753/5 084 301) of the population. Among 0–14-year-olds, ‘western’ utilisation (studies/103 people) exceeded ‘eastern’ by a factor of approximately 2.4 throughout. In patients > 14 years, the utilisation differential increased from 1.78 to 1.98 in the review period. Conclusion Ensuring equitable services on the same healthcare platform requires ongoing surveillance of resource and population distribution. MR access can serve as a proxy for equity in highly specialised services.


Introduction
By comparison, the South African, Zimbabwean, Nigerian, Zambian and Tanzanian public healthcare sectors have 0.33, 0.2, 0.11, 0.06 and 0.05 scanners/million people, respectively. 1,16,17,18,19 There is also wide global variation in the clinical utilisation of MR. For example, Germany, the US, Japan, Canada and the UK perform 131, 118, 112, 56 and 53 scans per 1000 citizens per year, respectively. 5 The WCP performed 2.5 scans per 1000 people in 2019. 7 There are also marked global disparities in the annual clinical workload of MR units. In 2019 MR scanners in Turkey, UK and Canada performed an average of 5993, 8025 and 9872 studies, respectively, 5,20 while WCP units performed an average of 4168 scans in 2017. 21 There also exists substantial variations in the distribution and utilisation of resources within countries. MR scanners are typically concentrated in the urban areas. This is particularly true in resource constrained environments, such as Southern Africa, where units are confined to the largest cities. 1,2,7,16,19,21 Additionally, in the US, persons who are 65 years and older undergo three times more MR investigations than their younger counterparts. 8 Equitable access to essential health services is a key consideration in the United Nations (UN) 2030 Agenda for Sustainable Development and its Sustainable Development Goals (SDGs). The overriding SDG commitment is to enable a more equitable distribution of essential global resources. 22 Although inequalities in access to health services between well-and poorly-resourced environments have been documented in considerable detail, there has been limited work on equitable access to scarce resources within the same healthcare system. 2,9,20,21 Ongoing appraisal of such access is important because healthcare infrastructure and referral pathways may lag changes in population size and distribution and contribute to unintended inequalities. 7,21 Population growth has been shown to be a key driver of demand for imaging services in the WCP of SA, with the latter demonstrating the second fastest provincial population growth nationally. 7 Therefore, regular and detailed analyses of both population distribution and resource provision and utilisation are necessary to ensure ongoing equity in healthcare. 21 Three quarters of the WCP population have no medical insurance and are therefore dependant on public sector health services. 23 These services are managed along two parallel referral pathways, which link the province's more peripheral facilities to the three central hospitals, namely Groote Schuur Hospital (GSH), Red Cross War Memorial Children's Hospital (RCWMCH) and Tygerberg Hospital (TBH). 24 These pathways have broad geographic constructs and can be conceptualised as 'western' and 'eastern'. GSH and RCWMCH together serve the 'western', while TBH serves the 'eastern' pathway. 25 The central hospitals have different bed capacities and patient profiles. GSH, built in 1938, is an adult, maternity, and neonatal centre. It has 893 beds, with 80 dedicated to the neonatal service. 26,27 RCWMCH was commissioned in 1956 and is an exclusively children's hospital with 300 beds. 28 TBH, built in 1976 to accommodate Cape Town's eastward expansion, provides adult, maternity, paediatric and neonatal services. It has 1386 beds, including 210 for paediatric and 90 for neonatal patients. 29,30 Each central hospital has a single MR unit. The GSH and TBH MRI units were both commissioned in 2002, while the RCWMCH unit was installed in 2008.
Quantifying MR service utilisation trends aids in defining service pressures and evolving needs. The WCP provides the ideal scenario for an analysis of such utilisation, with three hospitals encompassing different patient profiles across two drainage pathways. This study aimed to analyse publicsector MR utilisation in the WCP of SA.

Methods
This was a retrospective study of public sector MR utilisation in the WCP of SA in 2013 and 2018. Details of all MR investigations performed on WCP public sector scanners in the respective years were extracted from the official records of the Medical Imaging Services Sub-Directorate (MISSD) within the Directorate of Health Technology of the Western Cape Government Health (WCGH). Data were analysed for the whole province, and by the province's established 'western' and 'eastern' referral pathways for central services (see Tables 1a, b  For 2013 and 2018, population figures for the WCP as a whole, and the respective referral pathways, were extracted from the WCP Population Circular (2020), which provides data by year, geographic location, and age. 31 The analysis was based on 75.3% of the WCP population being dependent on public healthcare 21,23 and each of the three WCP central hospitals being equipped with a single MR scanner throughout the review period.
Access to, and utilisation of, MR services were expressed as units per million people and studies per 1000 people, respectively, for the whole province and for 'western' and 'eastern' referral pathways. Sub-analyses defined MR access and utilisation for people aged 0-14 years, and for those older than 14 years.

Ethical considerations
A retrospective study was performed using data freely available in the public domain.
Study approval was granted by the Stellenbosch University Health Research Ethics Committee (S20/10/296) and Tygerberg Hospital Management. The study was registered on the National Health Research Database (WC_202108_27).

Population Analysis for the whole province
Between 2013 and 2018, the WCP population dependent on public health services increased by approximately 455 250 people (8.2%, 4.63 vs 5.08 × 10 6 ) (

Discussion
To the best of our knowledge, this is the first study to assess equity in access to highly specialised services within the same public healthcare system at provincial level. Therefore, this work makes an important contribution to the discourse on equitable access to essential services, which is at the heart of the UN 2030 Agenda for Sustainable Development.
There are known disparities in healthcare between wellresourced and poorly resourced countries. 5 Similarly, there are known inequities between healthcare systems (private vs public) and provinces in the same country. 7,19,21,32 However, to date there has been scant recognition of potential inequalities that can unwittingly exist on the same healthcare platform in a single region, province, or city. This study highlights the key role that the distribution and utilisation of sophisticated radiological equipment can play in providing equity and access to services in this setting. High-end radiological equipment is typically capital and labour intensive, has specific installation and infrastructure requirements, and is registered by location with a regulatory authority. It thus provides the ideal yardstick for the measurement of access to highly specialised medical services.
The Western Cape is acknowledged as one of South Africa's most unequal provinces and is known to have increasing inequality, as measured by the Gini coefficient. 33 Furthermore, historically, the City of Cape Town (CCT) has had unequal development, with entrenched racial and economic divisions contributed by the combination of peninsular topography and the consequences of apartheid spatial planning. 34,35 These differences are manifest in the city's distribution of economic and health indicators. The 'eastern' pathway is known to have a higher rate of poverty and a greater burden of communicable diseases. 36 The key finding of this study is the unintended inequality in access to MR services between the two WCP referral Population growth is acknowledged as the major driver of WCP imaging utilisation. 21 The overall WCP population grew 9.8% in the 6 years of this investigation and was 6.75 million people in 2018. If one considers that the WCP population has grown 68%, from 4.3 million people at the time of commissioning one MR unit in each of the referral pathways in 2002, to a forecasted 7.2 million people in 2022, one can appreciate that current provincial MR resources have not kept pace with population growth. 37,38 Furthermore, the lesser resourced Eastern referral pathway drains a larger, younger, faster-growing population, with a lower socio-economic index and a higher burden of communicable disease. 33 It is noteworthy that the effect of population growth on access to finite resources is not limited to MR imaging but can be extrapolated to any centralised, highly specialised health service or public amenity.
A major strength of WCP healthcare is its meticulous, ongoing collection and analysis of data pertaining to the broad range of healthcare services and indicators, including diagnostic imaging. This is underscored by the establishment of the Sub-Directorate Medical Imaging Services in 2007, which is mandated to co-ordinate and assess clinical services, to enhance efficiency and to build capacity within the province's public sector radiographic services. It also provides advisory support to ensure implementation of, and adherence to, radiation-related legislation and policies.
Additionally, WCP referral pathways to the central services are well defined and carefully considered, taking into consideration transport routes for Emergency Medical Services (EMS), planned patient transport (HealthNet), and public transport. Differential local population growth is influenced by a range of complex socio-economic factors, and manifest over many years. As accurate data on local demographics (at sub-district) has become more available over the years, these are being factored into a system of 'equity-based resource allocation'. Another strategy to enhance equity would be the commissioning of a second scanner in the 'eastern' drainage pathway. Its potential impact on access to MR resources for the eastern drainage pathway would be an increase from 0.24 to 0.48 units/10 6 people. While significant, this is still below the current 'western' drainage pathway access of 0.64 MR units/10 6 people. Other possible interventions to advance equitable access to WCP health resources include the sharing of scanners across drainage pathways and the reconfiguring of population drainage areas. A possible short-term strategy to enhance equity would be further increasing scanning hours on the existing 'eastern' pathway scanner.
Strengths of this study are the meticulous Western Cape Provincial medical imaging and population datasets upon which this work is based. The study was limited by the lack of data on the hours of operation of the three MR units. A further limitation is the absence of an analysis on the impact of unequal access on clinical outcomes.
Suggested future work in this field of operational research includes an analysis of the impact of increased 'eastern' pathway MR scanning times on utilisation of services and the conduct of similar studies across other imaging modalities, particularly CT and mammography.

Conclusion
Ensuring equitable services on the same healthcare platform requires ongoing surveillance of resource and population distribution. MR access can serve as a proxy for equity in highly specialised services.
the methodology, formalised the research protocol, assisted in the administration of the ethics submission, detailed review and editing the final manuscript.

Funding information
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability
The data supporting the findings of this study are presented within the article as tables. Raw data from the MISSD and Population Circular are available from the corresponding author, Y.P.